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Permit No~
File No. f 7
TOWN OF SpU ,'HOLD
HIGHWAY DEPARTMENT
Pecon;c Lane
Peconic" New' York 11958
(516) 765c31110
Po. ';ol< /78
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref. II;) 3-0 I'ISf .aJa
APPLICATION IS HEREBY mede to the Superintendent of Highways of the Town
of Sauthald far the issuance of an Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Sauthold, Suffoik County, New York, and ather applicable laws,
ordinimces or regulations for the excavation herein described. The applicant agrees
to comply with al/ applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to make; necessarY..inspections of the jab site.
Print Or Type
1) KEY SPAN ENERGY 448 EAST MAIN STREET
Name 0 Applicant
PATCHOGUE N~I YORK
Address
Il727
2)
Name of Owner of Premises
Address
lei .lIe tU1 - t'I1.I1 II (L, (K
Cross Street)
3)
<. I.. A
Work Description and
(a) . Is construction located within 75 feet of tidal wetlands? 'Yes_No
*If yes, other-Town permIts may be required.
..---
~) BuJfder's License No.
prumber's License No.
Electrician's License No.
Other Trade's License No.
~j} J~~=-
Signature 0 Art
. 1- '1'01
Date
5) aJ Attach plat plan showing location of proposed excavation and relationship to
adjoining premises Or Publicstre.ets or are.., and giVing a detailed descrip-
tion of layout of excavation.
b) Atrach ail other necessary perrilits and licenses far this project.
c) \York covered by this application may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
6)
7)
8)
Tax Map; Section
Block
, Lot
Starting Date:
Work Schedule:
Completion Date
~
'\
Completion Date
Excavation.,.,......".,...... .,. '".,......,.."....
Facj[i ty Installation...........;'.,...................
Backfill & Compaction.........:....................
Pavement Replacement..,.,... ~',';.......,....,......
9) Under which authority i. the application made:
10) Estimated Cost of Proposed Wark:S
II) Remarks:
"
0-39
12) Insuranc. Cov.raq.: (Attach copy)
a) Insurance Company:
bJ Policy #
c} State whether policy of ce'~t.jfication on. file w the Highway Depart-
ment:
d) Coverage required extende~. to the Town:
Bodi[y injury and prop.rty damag.: $300 0/$500,000 Bodi[y Injury,
and $50,000 prop.rty damag..
13) S.curity:
a) Sur.ty Bond
total amount of $
b) Maint.nanc. Bond provid
or i=.rtif[.d Ch.ck
rovided in the
2 ye 5 or
3 years
14)
Basic A [] tion F.......... $25. 00
'..xcavations @ $20 0 ~ $ ~O. ()J
ns sam. s.rvic. @ 10.00 ~ $ / ~()
Fees for applications and permits:
A 1 . i IServ ice Connectio
~
A2. J IAdditional Excava
1To;-
B. Excavations 18tt in depth 1': less:
0- 1 00 I. f. ~ $ 10. 00 ..
l.f. @ $0.10 ~:$
Addit[onal
'C. Excavatlons...lS" in depth' 0 '5' in depth:
0-100 [.f. ~..$30.00
I.f. @ $0.30 .$
Additiona[
D. Excavations 5' in depth over:
0-100 l.f. ~ $50.00
l.f.@$0.50!'$
Additional i '
E.
Utility Repai Excavations @$10.
$
No.
Additional
Repairs sam
ervice@ $S. 00 ~
F. Notice to publicut![ities
this application prior to
'of must be provi'
uance of p.rmit.
and attacQed to
*
,i
.>
TAL COR-T-~S 55. ~
Authorization is hereby granted to the
Issue a Highway Excavation P.rmit to:
in accordance with ~this application.
wn Clerk of the
n of Southold to
Received by the Town Clerk
D.
Permit Issued,. / - "~ 0 /
Date
P.rmit No.
~:
Permit expires one (1) year
No work to start without 48
Permit must be available for
m Date of Issuan
u,r notice .to the S erintendent of Highways.
spection.
P~ge 2 af 3
"
1
.
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
D D NASSAU D SUFFOLK r-:;( -7:0. $,4"UTl-iot.b
STATE COUNTY COUNTY ~
MIS JOB DATE
NO. I - (, - 6 I
FC-6','1.~
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
f Is L I Vt. l..-A I; 0 I
U- Pt-f\-0L S'L~VI('t.--
FOREMAN
d~ - 07'1~rs-03D
M AldLs
s/o
!Vil/ f1 Ib'DLl... ~b
'Tf I -ru.C Ie....
DATE OF
OPENING
DEPARTMENT DIVISION
GAS CONSTR. MAINT. & SERVICES '2 If
DATE
A~AP
SKETCH
, ill ~ -:ft= 101 - 0 b ... b I S V
N
Date: 01/16/01
Transaction(s):
1 Permits
Check#: 1108
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk ID: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1108
Subtotal
$55.00
$55.00
IntemallD: 24731